Tobacco use presents a large disease burden, and rural populations have a higher prevalence of tobacco use than urban populations, with a widening disparity over time. Since the vast majority of tobacco users initiate during adolescence, this is a critical period in which to focus prevention and intervention efforts. Central to this is understanding the etiology of tobacco use and nicotine addiction. However, recent changes in tobacco use trends (namely the drastic rise in the use of electronic nicotine delivery systems (ENDS) have thwarted current understanding of nicotine addiction and prevention efforts. The current project will advance research on tobacco use among rural youth and translate those findings into prevention/intervention strategies. First, current tobacco use trends (multiple products) will be analyzed among rural populations and American Indian populations using the most recently available data. Second, the relationship of ENDS use with conventional cigarette smoking will be analyzed using causal inference methods, which will inform about the implications of ENDS on tobacco use trends among rural youth. Third, a system dynamics simulation method will compile these findings, as well as findings from existing literature, on the etiology of tobacco use. This system dynamics model will be tailored for rural youth and will be used to identify leverage points and corresponding intervention or prevention strategies that are appropriate for rural settings. The model will be analyzed to identify the strategies that are most likely to be effective at reducing tobacco use among rural youth. Finally, these findings will lead to implementation efforts within Sanford Health. Specifically, the PI will work with the healthcare delivery arm of her organization to improve data collection of tobacco use among and to implement appropriate interventions in healthcare settings to reduce youth tobacco use in rural areas.